1104963040 NPI number — EYE ASSOCIATES OF NEW MEXICO, LTD.

Table of content: (NPI 1104963040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104963040 NPI number — EYE ASSOCIATES OF NEW MEXICO, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE ASSOCIATES OF NEW MEXICO, LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104963040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8801 HORIZON BLVD NE
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-1533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-246-2622
Provider Business Mailing Address Fax Number:
505-213-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1623 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544-3018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-662-5444
Provider Business Practice Location Address Fax Number:
505-662-6109
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TERRY
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
KRISTIN
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
505-246-2622

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K5006 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47951 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN6728 . This is a "RAILROAD MEDICARE (RRB)" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: CH4370 . This is a "RAILROAD MEDICARE (RRB)" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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